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| ‘NW 88326

Assassination Records Review Board
Final Determination Notification

AGENCY : HSCA
RECORD NUMBER : 180-10070-10154
RECORD SERIES : STAFF PAYROLL RECORDS
AGENCY FILE NUMBER :..

December 8, 1995
Status of Document: Postponed in Part

Number of releases of previously postponed information: 7

Reason for Board Action: The Review Board's decision was premised on several factors
including: (a) the significant historical interest in the document in question; (b) the
absence of evidence that the release of the information would cause harm to the United
States or to any individual. |

Number of Postponements: 3

Postponements: All the postponements in this document represent Social Security numbers.

Reason for Board Action: The text is redacted because the public disclosure of the redaction could
reasonably be expected to constitute an unwarranted invasion of personal privacy, and that invasion of
privacy would be so substantial that it outweighs the public interest.

Substitute Language: SSN

Date of Next Review: 2017

Board Review Completed: 10/24/95

N

| Decid:327244096 Page 1

Date:08/20/93
Page:1
JFK ASSASSINATION SYSTEM

IDENTIFICATION FORM

AGENCY INFORMATION

HSCA

AGENCY :
RECORD NUMBER : 180-10070-10154

RECORDS SERIES
STAFF PAYROLL RECORDS

AGENCY FILE NUMBER :

ORIGINATOR : HSCA
FROM :
TO 3;

TITLE :;

DATE
PAGES

07/11/77
7

SUBJECTS ;
| HSCA; ADMINISTRATION
| SELLECK, ELIZABETH kK.

DOCUMENT TYPE : PRINTED FORM

:

| CLASSIFICATION : U

: RESTRICTIONS :;: 3

| CURRENT STATUS : P

DATE OF LAST REVIEW : 07/16/93

OPENING CRITERIA

COMMENTS

Box 3.

(R]) - ITEM IS RESTRICTED

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W 88326 —

“U.S. DEPARTMENT OF LABOR
EMPLOYMENT STANDARDS ADMINISTRATION-.-

Office of Workers’ Compensation Programs

December 15, 1978

File No: AQ3-146626
Date of Injury: May 25, 1978
- - SSN: 531-500-7761
.Ms, Elizabeth K. Selleck
‘ 4201 Cathedral Avenue —
Washington, DC. 20016
2 We need additional information to make a determination regarding the

claim you submitted for the injury indicated above. Please furnish the
information requested in the items checked below and onthe reverse of
this form, Use a separate sheet of paper numbering the answers to cor-

respond with the question numbers,

[x | 1. The Federal Employees' Compensation Act requires an injured
employee to give written notice of injury to his/her supervisor ©
within 30 days. | State why. this injury was not reported to

your supervisor within ,that time.

x | 2. Describe in detail exactly how the injury occurred, (For
example, if you fell, state. how far you fell, how you landed,
etc. If lifting was the cause of injury, describe the object
handled, its weight, what you did with it, etc.).

~~ (

Z| .3: Give the names of any persons who witnessed your injury or

. had immediate knowledge of it.

Supervisory Claims Examiner

Select Comm. on Assass-inations
~ .HOuse of Representatives <

HOB #2 2

Washington, DC. 20515

Ltr. CA-1011

’ a (+. Include your address, ZIP code, and file number on all correspondence June 1975

rochd:32244096 Page 3

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State the immediate effects ofthe injury~ and what you-did immedi-

ately thereafter,

Was: any. other. injury sustained, either on or off duty, between. the Bo
‘date of: injury and the date it was first. reported to. (a) your super= >. oo
visor and (b) to a doctor? | If so, describe: - eo J Of

State the exact reason why you delayed seeking medical attention;
-also. give the name and address of the doctor.you first consulted

and the date you were first examined for this injury:

Describe (a) your condition between the date of the injury and the

-date you first received: medical attention, and (b) the nature.and

frequency of any home treatment:

Did you have any similar disability or symptoms before the injury? If

so, describe the prior condition. Give the names and addresses of the

‘physicians who: treated you.and the approximate dates you. were treated:

Did you ever file a claim for workers' compensation benefits from
any source? If so, give the date and nature of the injury, the name
and address of the office where the claim was filed, and describe
the benefits (if any) which you received:

\

Arrange for submission of a medical report on the enclosed Form CA=20
from the private physician who examined you as a result of this injury.

ae ee et a we

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U.S. DEPARTMENT OF LABOR
EmpLoyMENT STANDARDS ADMINISTRATION
. Office of Workers’ Compensation Programs | ae
December 15, 1978 oo, File No.: A25-146626
. . Date of Injury: May 25, 1978
Employee:. Selleck Elizabeth Kk.

_ Noncontroverted [_] Controverted [_]

Select Com. on Assassinations
House of Representatives iy
HOB #2 _— a oe
Washington, DC. 20515 |

We have received Form CA-1 reporting an injury and your agency's response
‘to the evidence submitted. It has been determined that:

[| 1. The facts of the injury and employment support the employee's
contention that he/she was a Federal employee who sustained a
traumatic disabling injury in the performance of duty. You
should, therefore, continue his/her pay, for the period of dis-— -
ability not to exceed 45 days. - \

[X] 2. The information of record is insufficient to make a decision on \
the case;. however, you should continue the employee's pay without
interruption. Additional information is required as noted on. the
reverse of this letter.

aaa cal

BLT and ms Examiner — | , |

| Ms. Elizabeth K. Selleck
4201 Cathedral Avenue
. Washington, DC. 20016

Ltr. CA-1038
Include your address, ZIP code, and file number on all correspondence . Rev. Apr. 1977

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rochd:32244096 Page 5 ‘ et , :


-SELLECK, Elizabeth. | - | eer ee

Hime of Employee

OFFICE OF THE CLERK” Se
a ae U.S, HOUSE OF REPRESENTATIVES DALANce nnoucut
7 — ae . ; a a ORWAPD FROM
a — PERSONAL LEAVE RECORD © ARG

. 7 . ; ” . Famer aamean soaeentunneereaebenenninaetaeed os . _ . . 7 . . o
: - Audress . . : oe ee YEAR .
— a . WHAT LRAY -. ; 7 oy
_ DATE OF APPOINTMENT ANN Gone 7 a
. Phone Number : a _ CATEGORY ae ;
J-1-77. THOR ts
| | Ww Oo PO oot,
Tee ee ee ee ematianammeneamennnemenmanetedl . co ‘ . Lo
Posilion Title . : . . . _ a
oo PRIOR FEOERAL scavice | . 25 . (]
enamine = tee on oe saree es een ae ony ererenencne rain rotted ‘| seeeesnvreesesen | Pawn neenecoaen ‘i 7 CCR! AVAILASL ; : USE . RALANSE |
2 Position Number bevel _ Step Yeats Menths 20 0 miswonn | otis wontd | ting Mone | oe Ages 34
. ; no MOUTH os
¥ ~ 7 RT and
: Heath Annual Sick Annual Sick Anaual Sick 22
- Leave Leave Leave Leave | Leave Leave

Soe wenemucenteteanammante
ba. Z L1&
an a - _- f :
Feb. 7 f Do / 7
Mar. —f | oF Kl.
Apt. 7 . / }
"May - A& lo
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ae Aug. . oy .
i Se reinemmmnnendl
Sept. - ; ;
| Oct. ~
i Nov,
—-
; Dee.
Q.5 day annual leave CERTIFIED CORRECT:
1.0 day annual leave ere , coe :
= 05 day sick leave . . . . :
oof - eae cS eee UR PET ELL CE Pen CY Sos eeenenenenneneeseeienaed
= 1.0 day sick leave an _ _ - Employeo's Signature Pte ; " Chiaf's Signature : Date
me . co + if employee ecfuses to sign, state reason below) oe so _
= 0.5. day administrative leave re
4.0 day administrative Icave Be Os So Approved: _- soem —_————
ow ; : . ; ae : ; ‘ Clerk cf the Houso . ; - ; Dato
oz 0.5. day unauthorized absence Se , ; : , : . ; : er : _ >
This record. will be forwarded to the Clerk of the House at the end of cach cafenddr year, or In case of termination, along | :

1.0 day unaulhorized absence - "with the request for termination. Upon approval, the record will be filed in the employee's official personnel foider, -

a 0.5. day leave without pay

; 1.0 day leave without

pay

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yrhv od


ae

- (If type of action is an Appointment, Salary Adjustment, or Title Change, complete appropriate information below.)

PAYROLL AUTHORIZATION FORM

. (Please Use Typewriter . Cc} U.S. HOUSE OF REPRESENTATIVES) (Any erasures, corrections, or changes

or Ballpoint Pen) Washington, D.C. 20515 suthotieing official} initialed by the

To the Clerk of the House of Representatives:

| hereby authorize the following payroll action:

Employee Name (First-Middle-Last)

7/15/78

Type of Action

C1 Appointment
O Salary Adjustment
Of Title Change

Ci{termination (At close of business on effective date) —

Llizgabeth Kk. Selleck

Employee Social Security Number

537-50-7761
Employing Office or Committee/Subcommittee

Assassinatians

0) Leave without pay (Beginning with effective date above and ending |

close of business... -§. § >= = )
Specify Date

Position Title -

Gross Annual Salary*

_ * If emoloyee is a civil service annuitant (includes U.S. House of Representatives), the gross annual salary shown should include the annuity received by the employee

plus the salary received ‘from the employing office.

. (If Committee Employee, complete appropriate item below.)

1. 0 Standing Committee: Staff—C] Clerical or 1 Professional.

2. @ Special (Investigative staff of Standing Committee) or Select Committee: Authority—H. Res. 325 of 234 congress.
3. O Joint Committee.

(If Employee of an Officer of the House, complete item below.)

Position Number If applicable, Level

‘| certify that this. authorization is not in violation of 5 U.S.C. 3110(b), prohibiting the employment of
relatives. ’

july 7 73
vuly e
Date_____“=* too pW
, (Signature of Authorizing Official)
wave OAL

LOUIS STOKES, CHAGHRAN
(if appropriate, signature of Subcommittee Chairman or Ranking Minority Member) ~=~=~S~S*S*S*”~S*:S*Sype ov print nome of Authorizing Offaly)
7 (Type or print name and title of above official). == Fee GFitle=If Member, Districtand State). SSCS

All appointments and. salary adjustments for employees under. the House Classification Act and for Committee em-
ployees, except those of the Committee on Appropriations, the Committee on. the Budget, and the Joint-Committees, must:
be approved by the Committee on House. Administration.

Chairman, Committee on House Administration

APPROVED:

2

‘ Office of Finance use only:

Office Code

W 88326 | ae ae

1d:32244096 Page 8 : vos ;

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——

PAYROLL AUTHORIZATION FORM.

(Pledse Use Typewriter .
_ or Ballpoint Pen).

~ | hereby authorize the

“

i Employee

f

_ To the Clerk of the House of Representatives:

é

following payroll-action:

Name (First-Middle-Last)

‘(J Termination (At close of business on. effective date)

A “US: -HOUSE OF: REPRESENTATIVES -.
7 . Washington, D.C: 20515

PALLST? .

«(any erasures, corrections, or changes ~
this form must he initialed by the |. |.
authorizing official.)

Effective Date

&] Appointment

, am Salary Adjustment

Type of Action

(If Committee Employee, complete appropriate item below.)

1. CJ Standing Committee: Staff—[_] Clerical or [_] Professional.

2. &] Special or Select Committee: Authority— H. Res. ASS of _2

3. (] Joint Committee.

(If Employee of an Officer of the House, complete item below.)

Position Number

relatives.

_o ee If applicable; Level

Sahy 22 ; 1977

85

SthCongress.

| certify. that this authorization is not in. violation of 5 U.S.C..3110(b), prohibiting the employment of-- |

All appointments and salary adjustménts for employees. under the House Classification Act and - for Committee em- .
ployees, except those of the Committee on Appropriations; the Committee. on the Budget, and the Joint Committees; ‘must
be- approved by the Committee on House Administration.

_ APPROVED:
Office of Finance use only: ~ °
Office Code
Monthly Annuity $__- 00

Copy for Initiating

Office or Committee


MEMORANDUM

TO: ALL STAFF | | Oo Be |

RE: Payroll Certification . . 7 . : ob

The Regulations and Accounting Procedures for Allowances and _
Expenses of Committees, Members and Employees of the U.S. House of. en |
Representatives require that, among other things, tne Committee's ve |

. monthly payroll certification include the relati onship, if any, of | .
- each employee to any current Member of Congress. This certification
is Signed monthly by our Chairman.

The following: are “the relationships to be “included in the et
certification: .

Father . nephew . brother-in-law
_mother niece - sister-in-law
son . ~ husband stepfatner
daughter wife -. stepmother
brother father-in-law stepbrotner. oo a
sister _ mother-in-law sss Stepsister oo \
uncle _ son-in-law . half-brother \
aunt = . daughter-in-law half-sister . a \
first cousin -
| ‘Piease complete the appropriate portion below, sign and date ete
this form, which will then become a part of your permanent personnel.
| File. if this status changes, you must notify the Committee's Budget
7 Of¥ice Jinmediately of the change.
| Xi I am not related to any current (95th Congress) Member of Congress.
:
fo /-/ 1 am related to a current (95th Congress} Member of Congress.
I (Please specify.) ee _
4
4

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